Abstract
BackgroundLocalizing and removing the infected sequestrum in long-standing trauma-related chronic osteomyelitis remains a clinical challenge. PET/CT with 18F-fluorodeoxyglucose (FDG-PET) has a high sensitivity for chronic osteomyelitis and 18F-sodium-fluoride PET/CT (NaF-PET) has a high specificity for identifying non-viable bone. Combining both, high signal on FDG-PET in the bone without signal on NaF-PET could potentially guide surgery to become more precise with curative intent.Eight patients with long-standing (average 22 years) posttraumatic (n = 7) or postoperative (n = 1) chronic osteomyelitis in the lower extremity and with multiple futile attempts for curative surgery were recruited in this prospective pilot study. FDG-PET and NaF-PET were performed within a week in between using standard scanning protocols. The most likely location of the culprit sequestrum was identified and was surgically removed. Based on perioperative tissue cultures, antibiotics were given for 6–8 months. Dual-tracer (FDG- and NaF-PET/CT) was performed again after 12 months to rule out persisting signs of infection.ResultsA likely culprit sequestrum could preoperatively be identified by dual-tracer PET in all eight cases and in four cases an additional sequestrum was identified at a location with no clinical sign of infection. The infected necrotic tissue was removed during surgery. Follow-up dual-tracer PET revealed no signs of persistent infection. All patients recovered with no clinical signs of recurrence for a follow-up of mean 4.5 (SD 1.3) years.ConclusionsDual-tracer PET/CT with FDG and NaF allows successful precise surgery with curative intent in patients with long-standing complicated posttraumatic chronic osteomyelitis with severely deranged anatomy.
Highlights
Localizing and removing the infected sequestrum in long-standing trauma-related chronic osteomyelitis remains a clinical challenge
In patients with long-standing posttraumatic chronic osteomyelitis (PTO), where the fracture already has healed and the metal implant has been removed, the clinical history with recurrent pain and fistulation is often sufficient for making the right diagnosis, and in these cases, the higher precision in PET/CT outweighs the problem with lower specificity
Perioperative tissue cultures were positive in all eight patients, confirming the diagnosis of PTO
Summary
Localizing and removing the infected sequestrum in long-standing trauma-related chronic osteomyelitis remains a clinical challenge. 18F-fluorodeoxyglucose (FDG) PET/CT is commonly used for imaging in evaluation of malignancies, but is very sensitive for osteomyelitis due to high accumulation of the tracer in activated leukocytes [7]. Both FDG-PET/CT and MRI have a high and comparable sensitivity for qualitative detection of chronic osteomyelitis. In patients with long-standing posttraumatic chronic osteomyelitis (PTO), where the fracture already has healed and the metal implant has been removed, the clinical history with recurrent pain and fistulation is often sufficient for making the right diagnosis, and in these cases, the higher precision in PET/CT outweighs the problem with lower specificity
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